1. Implementation of an Enhanced Recovery Program (ERP) for Lower Extremity Bypass
Adam W. Beck, M.D.
Associate Professor of Surgery
Division of Vascular Surgery and Endovascular Therapy
University of Alabama at Birmingham
June 12th, 2019

2. No relevant Disclosures

3. ERAS is not a new concept…1995
Dr. Henrik Kehlet MD, PhD
Considered the founder of ERAS

4. How does eras work? Patients can drink up to 2hrs prior to surgery
Regular diet night of surgery
Mobilize Day of Surgery
Minimize opioid use
Minimize Intravenous Fluids
Only get 1 set of labs

5. ERAS is not a new concept…1995
8 patients
Laparoscopic approach
Epidural analgesia
Early oral nutrition
Early mobilization
6 patients went home POD2
2 patients went home POD3
Average LOS after a colectomy at the time was 5-10 days
Lancet

6. What is Eras? Reduce length of stay by up to 30-50%.
Reduce post-operative complications up to 50%.
Save up to $6,000 per patient for hospital stay.
Significantly reduces or eliminates racial disparities in LOS, readmissions, and POCs.
Reduces opioid use.
Strict adherence associated with reduction in 5 year mortality by 42% in cancer patients.

7. How does eras work? Themes of ERAS
“Perioperative care, not the actual operation, can dictate outcomes”
Minimize stress and improve response to stress
Patient centered approach
Evidence based, “best practice” medicine
Relies on multidisciplinary team approach

8. ErP vascular? Vascular surgery patients often:
Multiple medical comorbidities
Lower socioeconomic/educational level
High risk for perioperative complications
High risk for SSI
High risk for unplanned readmissions
Lower extremity bypass patients perhaps highest risk...good population for ERP?
Excluded patients undergoing open surgical inflow procedures as well as trauma patients.

9. Implementation UAB Care team Care pathway transformation
Many previous ERAS/ERP programs with various disciplines (use your institutional knowledge)
Our team: vascular surgeons, anesthesiologists, rehabilitation physicians, physical therapists, wound care specialists, dieticians, pharmacists, pain management specialists, advanced practice providers, and nursing staff
Physician champions: Vascular surgeon & Anesthesiologist
Administrative support
Initial Visit:
Identify Patients who are currently smoking at intake
Smoking Cessation Clinic Protocol:
Follow up visit
No Follow up Visit
Current smoking status identified at intake
Did the patient join any cessation programs?
Have they used medication?
If the patient did not quit, offer medication again and discuss importance again
If successfully quit, make sure to discuss and praise success
Nurse/Quality Manager contact via phone once a month regarding smoking status
Do they need refills or need to speak to a provider?
Patient Education
Supportive and empathetic discussion
Discuss the importance of smoking cessation
Acknowledge that quitting is hard, do not trivialize
Explain why tobacco is addicting, how medication can help and how it works
Help to choose a low stress quit date
Recommend elimination of cigarettes from home and remove potential triggers
Encourage other family members to quite (especially if present)
Medication
First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)
Start Wellbutrin/NRT 7 days prior quit day
Chantix if patient prefers or if contraindication to Wellbutrin.
No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date
Discuss side effects (if not discussed, patient is likely to stop medication)
Provide written educational materials reinforcing discussion and medication regimen
Recommend patients consult the QUIT-NOW ( )
Document Smoking Cessation Intervention in EMR
Document in EMR
Initial Visit:
Identify Patients who are currently smoking at intake
Smoking Cessation Clinic Protocol:
Follow up visit
No Follow up Visit
Current smoking status identified at intake
Did the patient join any cessation programs?
Have they used medication?
If the patient did not quit, offer medication again and discuss importance again
If successfully quit, make sure to discuss and praise success
Nurse/Quality Manager contact via phone once a month regarding smoking status
Do they need refills or need to speak to a provider?
Patient Education
Supportive and empathetic discussion
Discuss the importance of smoking cessation
Acknowledge that quitting is hard, do not trivialize
Explain why tobacco is addicting, how medication can help and how it works
Help to choose a low stress quit date
Recommend elimination of cigarettes from home and remove potential triggers
Encourage other family members to quite (especially if present)
Medication
First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)
Start Wellbutrin/NRT 7 days prior quit day
Chantix if patient prefers or if contraindication to Wellbutrin.
No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date
Discuss side effects (if not discussed, patient is likely to stop medication)
Provide written educational materials reinforcing discussion and medication regimen
Recommend patients consult the QUIT-NOW ( )
Document Smoking Cessation Intervention in EMR
Document in EMR

10. Lower Extremity Bypass ERP Goals
Create and implement the ERP pathways for our lower extremity bypass population.
Identify patients who undergo Lower Extremity Bypass and track goal project outcomes of:
At least 80% use of ERP in eligible LEB patients
Reduction of the observed to expected LOS index
Reduction in percentage of 30-day all cause readmission
Reduction in SSI rate
Reduction of variable cost per case.
It’s difficult to improve quality if we don’t define what quality is. In order to do that we must measure our outcomes, benchmark our outcomes and compare to other surgeons, and we must minimize variation in the way we do things.

11. UAB ERAS pathways
Existing UAB ERAS pathways are based on ERAS society guidelines
2014- Colorectal
2015- Surgical Oncology
2016- Gynecology Oncology
2018- Vascular

12. Implementation Transformational process!
Plan-Do-Check-Adjust (PDCA) methodology
Requires collaboration of teammates
Repeated re-evaluation of initiatives: Redesign
Initial Visit:
Identify Patients who are currently smoking at intake
Smoking Cessation Clinic Protocol:
Follow up visit
No Follow up Visit
Current smoking status identified at intake
Did the patient join any cessation programs?
Have they used medication?
If the patient did not quit, offer medication again and discuss importance again
If successfully quit, make sure to discuss and praise success
Nurse/Quality Manager contact via phone once a month regarding smoking status
Do they need refills or need to speak to a provider?
Patient Education
Supportive and empathetic discussion
Discuss the importance of smoking cessation
Acknowledge that quitting is hard, do not trivialize
Explain why tobacco is addicting, how medication can help and how it works
Help to choose a low stress quit date
Recommend elimination of cigarettes from home and remove potential triggers
Encourage other family members to quite (especially if present)
Medication
First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)
Start Wellbutrin/NRT 7 days prior quit day
Chantix if patient prefers or if contraindication to Wellbutrin.
No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date
Discuss side effects (if not discussed, patient is likely to stop medication)
Provide written educational materials reinforcing discussion and medication regimen
Recommend patients consult the QUIT-NOW ( )
Document Smoking Cessation Intervention in EMR
Document in EMR
Initial Visit:
Identify Patients who are currently smoking at intake
Smoking Cessation Clinic Protocol:
Follow up visit
No Follow up Visit
Current smoking status identified at intake
Did the patient join any cessation programs?
Have they used medication?
If the patient did not quit, offer medication again and discuss importance again
If successfully quit, make sure to discuss and praise success
Nurse/Quality Manager contact via phone once a month regarding smoking status
Do they need refills or need to speak to a provider?
Patient Education
Supportive and empathetic discussion
Discuss the importance of smoking cessation
Acknowledge that quitting is hard, do not trivialize
Explain why tobacco is addicting, how medication can help and how it works
Help to choose a low stress quit date
Recommend elimination of cigarettes from home and remove potential triggers
Encourage other family members to quite (especially if present)
Medication
First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)
Start Wellbutrin/NRT 7 days prior quit day
Chantix if patient prefers or if contraindication to Wellbutrin.
No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date
Discuss side effects (if not discussed, patient is likely to stop medication)
Provide written educational materials reinforcing discussion and medication regimen
Recommend patients consult the QUIT-NOW ( )
Document Smoking Cessation Intervention in EMR
Document in EMR

13. ERAS Implementation Leading Practice Guidelines
Literature Review
Leading Practice Guidelines
Physician Champions
Implementation Meetings
Multidisciplinary Teams
Pre-operative
Intra-operative
Post-operative
ERAS Vascular
ERAS
Sustainment meetings

14. Preoperative phase Emphasis on patient education Early mobility
Post-operative pain control
Planned length of hospital stay

15. Smoking Cessation Protocol
Initial Visit:
Identify Patients who are currently smoking at intake
Smoking Cessation Clinic Protocol:
Follow up visit
No Follow up Visit
Current smoking status identified at intake
Did the patient join any cessation programs?
Have they used medication?
If the patient did not quit, offer medication again and discuss importance again
If successfully quit, make sure to discuss and praise success
Nurse/Quality Manager contact via phone once a month regarding smoking status
Do they need refills or need to speak to a provider?
Patient Education
Supportive and empathetic discussion
Discuss the importance of smoking cessation
Acknowledge that quitting is hard, do not trivialize
Explain why tobacco is addicting, how medication can help and how it works
Help to choose a low stress quit date
Recommend elimination of cigarettes from home and remove potential triggers
Encourage other family members to quite (especially if present)
Medication
First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)
Start Wellbutrin/NRT 7 days prior quit day
Chantix if patient prefers or if contraindication to Wellbutrin.
No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date
Discuss side effects (if not discussed, patient is likely to stop medication)
Provide written educational materials reinforcing discussion and medication regimen
Recommend patients consult the QUIT-NOW ( )
Document Smoking Cessation Intervention in EMR
Document in EMR
Initial Visit:
Identify Patients who are currently smoking at intake
Smoking Cessation Clinic Protocol:
Follow up visit
No Follow up Visit
Current smoking status identified at intake
Did the patient join any cessation programs?
Have they used medication?
If the patient did not quit, offer medication again and discuss importance again
If successfully quit, make sure to discuss and praise success
Nurse/Quality Manager contact via phone once a month regarding smoking status
Do they need refills or need to speak to a provider?
Patient Education
Supportive and empathetic discussion
Discuss the importance of smoking cessation
Acknowledge that quitting is hard, do not trivialize
Explain why tobacco is addicting, how medication can help and how it works
Help to choose a low stress quit date
Recommend elimination of cigarettes from home and remove potential triggers
Encourage other family members to quite (especially if present)
Medication
First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)
Start Wellbutrin/NRT 7 days prior quit day
Chantix if patient prefers or if contraindication to Wellbutrin.
No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date
Discuss side effects (if not discussed, patient is likely to stop medication)
Provide written educational materials reinforcing discussion and medication regimen
Recommend patients consult the QUIT-NOW ( )
Document Smoking Cessation Intervention in EMR
Document in EMR

16. Fascia Iliaca/Sciatic Block
Perioperative phase
Chlorhexidine showers
Preoperative hair clipping
Non-opioid analgesia in preoperative holding area
Placement of fascia iliaca block by Inpatient Pain Service (IPS)
Fascia Iliaca/Sciatic Block
Anesthesia of the anterior and medial thigh (femoral nerve) as well as the anterolateral thigh (lateral femoral cutaneous nerve)
Able to be placed in patients receiving antiplatelet therapy
Avoids use of an indwelling catheter which might limit early mobility

17. Intraoperative phase Anesthesiologists Goal directed fluid management
Maintain normothermia
Non-opioid pain adjuncts
Lung protective ventilation
Post-operative nausea prophylaxis
Surgeons
Skin closure protocol
Separate instrument set for skin closure
Changing of gowns/gloves, and changing of the overhead operative light handles
Two wound closure methods
Interrupted vicryl sutures with staples on the skin and a sterile occlusive dressing (OPSITE Post op, Smith & Nephew, London, UK) or
Interrupted vicryl sutures with subcuticular moncryl and skin glue.

18. Postoperative phase Early mobilization Diet Tobacco cessation
POD0- Edge of bed
POD1- Out of bed, daily mobility milestones set by PT
Diet
Regular diet immediately after arrival to surgical floor
Tobacco cessation
Consult placed to UAB Tobacco Cessation team who visit the patient for bedside counseling typically on their second postoperative day

19. ERAS UAB Powerplan

20. Demographics Smoking Cessation Clinic Protocol:
Initial Visit:
Identify Patients who are currently smoking at intake
Smoking Cessation Clinic Protocol:
Follow up visit
No Follow up Visit
Current smoking status identified at intake
Did the patient join any cessation programs?
Have they used medication?
If the patient did not quit, offer medication again and discuss importance again
If successfully quit, make sure to discuss and praise success
Nurse/Quality Manager contact via phone once a month regarding smoking status
Do they need refills or need to speak to a provider?
Patient Education
Supportive and empathetic discussion
Discuss the importance of smoking cessation
Acknowledge that quitting is hard, do not trivialize
Explain why tobacco is addicting, how medication can help and how it works
Help to choose a low stress quit date
Recommend elimination of cigarettes from home and remove potential triggers
Encourage other family members to quite (especially if present)
Medication
First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)
Start Wellbutrin/NRT 7 days prior quit day
Chantix if patient prefers or if contraindication to Wellbutrin.
No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date
Discuss side effects (if not discussed, patient is likely to stop medication)
Provide written educational materials reinforcing discussion and medication regimen
Recommend patients consult the QUIT-NOW ( )
Document Smoking Cessation Intervention in EMR
Document in EMR
Initial Visit:
Identify Patients who are currently smoking at intake
Smoking Cessation Clinic Protocol:
Follow up visit
No Follow up Visit
Current smoking status identified at intake
Did the patient join any cessation programs?
Have they used medication?
If the patient did not quit, offer medication again and discuss importance again
If successfully quit, make sure to discuss and praise success
Nurse/Quality Manager contact via phone once a month regarding smoking status
Do they need refills or need to speak to a provider?
Patient Education
Supportive and empathetic discussion
Discuss the importance of smoking cessation
Acknowledge that quitting is hard, do not trivialize
Explain why tobacco is addicting, how medication can help and how it works
Help to choose a low stress quit date
Recommend elimination of cigarettes from home and remove potential triggers
Encourage other family members to quite (especially if present)
Medication
First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)
Start Wellbutrin/NRT 7 days prior quit day
Chantix if patient prefers or if contraindication to Wellbutrin.
No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date
Discuss side effects (if not discussed, patient is likely to stop medication)
Provide written educational materials reinforcing discussion and medication regimen
Recommend patients consult the QUIT-NOW ( )
Document Smoking Cessation Intervention in EMR
Document in EMR

21. Process Metric Assessment
Manual process audit
Process metrics audited and measured:
scheduling of the surgery as ERP
completion of patient education
diabetes patient optimization process
multimodal medications
regional block
tobacco cessation process
early diet
early mobility.
Automated monthly using Vizient (UHC) quality data
Readmission, LOS, LOS index, SSI, %ERP enrolled, variable cost
Initial Visit:
Identify Patients who are currently smoking at intake
Smoking Cessation Clinic Protocol:
Follow up visit
No Follow up Visit
Current smoking status identified at intake
Did the patient join any cessation programs?
Have they used medication?
If the patient did not quit, offer medication again and discuss importance again
If successfully quit, make sure to discuss and praise success
Nurse/Quality Manager contact via phone once a month regarding smoking status
Do they need refills or need to speak to a provider?
Patient Education
Supportive and empathetic discussion
Discuss the importance of smoking cessation
Acknowledge that quitting is hard, do not trivialize
Explain why tobacco is addicting, how medication can help and how it works
Help to choose a low stress quit date
Recommend elimination of cigarettes from home and remove potential triggers
Encourage other family members to quite (especially if present)
Medication
First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)
Start Wellbutrin/NRT 7 days prior quit day
Chantix if patient prefers or if contraindication to Wellbutrin.
No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date
Discuss side effects (if not discussed, patient is likely to stop medication)
Provide written educational materials reinforcing discussion and medication regimen
Recommend patients consult the QUIT-NOW ( )
Document Smoking Cessation Intervention in EMR
Document in EMR
Initial Visit:
Identify Patients who are currently smoking at intake
Smoking Cessation Clinic Protocol:
Follow up visit
No Follow up Visit
Current smoking status identified at intake
Did the patient join any cessation programs?
Have they used medication?
If the patient did not quit, offer medication again and discuss importance again
If successfully quit, make sure to discuss and praise success
Nurse/Quality Manager contact via phone once a month regarding smoking status
Do they need refills or need to speak to a provider?
Patient Education
Supportive and empathetic discussion
Discuss the importance of smoking cessation
Acknowledge that quitting is hard, do not trivialize
Explain why tobacco is addicting, how medication can help and how it works
Help to choose a low stress quit date
Recommend elimination of cigarettes from home and remove potential triggers
Encourage other family members to quite (especially if present)
Medication
First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)
Start Wellbutrin/NRT 7 days prior quit day
Chantix if patient prefers or if contraindication to Wellbutrin.
No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date
Discuss side effects (if not discussed, patient is likely to stop medication)
Provide written educational materials reinforcing discussion and medication regimen
Recommend patients consult the QUIT-NOW ( )
Document Smoking Cessation Intervention in EMR
Document in EMR

22. Team Compliance Smoking Cessation Clinic Protocol:
Initial Visit:
Identify Patients who are currently smoking at intake
Smoking Cessation Clinic Protocol:
Follow up visit
No Follow up Visit
Current smoking status identified at intake
Did the patient join any cessation programs?
Have they used medication?
If the patient did not quit, offer medication again and discuss importance again
If successfully quit, make sure to discuss and praise success
Nurse/Quality Manager contact via phone once a month regarding smoking status
Do they need refills or need to speak to a provider?
Patient Education
Supportive and empathetic discussion
Discuss the importance of smoking cessation
Acknowledge that quitting is hard, do not trivialize
Explain why tobacco is addicting, how medication can help and how it works
Help to choose a low stress quit date
Recommend elimination of cigarettes from home and remove potential triggers
Encourage other family members to quite (especially if present)
Medication
First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)
Start Wellbutrin/NRT 7 days prior quit day
Chantix if patient prefers or if contraindication to Wellbutrin.
No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date
Discuss side effects (if not discussed, patient is likely to stop medication)
Provide written educational materials reinforcing discussion and medication regimen
Recommend patients consult the QUIT-NOW ( )
Document Smoking Cessation Intervention in EMR
Document in EMR
Initial Visit:
Identify Patients who are currently smoking at intake
Smoking Cessation Clinic Protocol:
Follow up visit
No Follow up Visit
Current smoking status identified at intake
Did the patient join any cessation programs?
Have they used medication?
If the patient did not quit, offer medication again and discuss importance again
If successfully quit, make sure to discuss and praise success
Nurse/Quality Manager contact via phone once a month regarding smoking status
Do they need refills or need to speak to a provider?
Patient Education
Supportive and empathetic discussion
Discuss the importance of smoking cessation
Acknowledge that quitting is hard, do not trivialize
Explain why tobacco is addicting, how medication can help and how it works
Help to choose a low stress quit date
Recommend elimination of cigarettes from home and remove potential triggers
Encourage other family members to quite (especially if present)
Medication
First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)
Start Wellbutrin/NRT 7 days prior quit day
Chantix if patient prefers or if contraindication to Wellbutrin.
No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date
Discuss side effects (if not discussed, patient is likely to stop medication)
Provide written educational materials reinforcing discussion and medication regimen
Recommend patients consult the QUIT-NOW ( )
Document Smoking Cessation Intervention in EMR
Document in EMR

23. Central Goals: Results to Date
Baseline
ERP
P-value
Eligible patients
189 57
ERAS % NA
69%
Average LOS
11.1 ± 10.1
8.3 ± 8.4
0.056
Postop LOS
8.0 ± 7.5
6.1 ± 6.0
0.089
Observed:Expected LOS
1.8 ± 1.4
1.3 ± 0.7
<0.001
SSI %
5.8%
3.5%
0.499
Readmission %
21.6%
7.0%
0.012
Variable Cost/Case
18,777 ± 19,118
13,207 ± 9,930
0.004
Total Cost/Case
40,328 ± 37,820
29,865 ± 22,110
0.010
SSI
Initial Visit:
Identify Patients who are currently smoking at intake
Smoking Cessation Clinic Protocol:
Follow up visit
No Follow up Visit
Current smoking status identified at intake
Did the patient join any cessation programs?
Have they used medication?
If the patient did not quit, offer medication again and discuss importance again
If successfully quit, make sure to discuss and praise success
Nurse/Quality Manager contact via phone once a month regarding smoking status
Do they need refills or need to speak to a provider?
Patient Education
Supportive and empathetic discussion
Discuss the importance of smoking cessation
Acknowledge that quitting is hard, do not trivialize
Explain why tobacco is addicting, how medication can help and how it works
Help to choose a low stress quit date
Recommend elimination of cigarettes from home and remove potential triggers
Encourage other family members to quite (especially if present)
Medication
First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)
Start Wellbutrin/NRT 7 days prior quit day
Chantix if patient prefers or if contraindication to Wellbutrin.
No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date
Discuss side effects (if not discussed, patient is likely to stop medication)
Provide written educational materials reinforcing discussion and medication regimen
Recommend patients consult the QUIT-NOW ( )
Document Smoking Cessation Intervention in EMR
Document in EMR
Initial Visit:
Identify Patients who are currently smoking at intake
Smoking Cessation Clinic Protocol:
Follow up visit
No Follow up Visit
Current smoking status identified at intake
Did the patient join any cessation programs?
Have they used medication?
If the patient did not quit, offer medication again and discuss importance again
If successfully quit, make sure to discuss and praise success
Nurse/Quality Manager contact via phone once a month regarding smoking status
Do they need refills or need to speak to a provider?
Patient Education
Supportive and empathetic discussion
Discuss the importance of smoking cessation
Acknowledge that quitting is hard, do not trivialize
Explain why tobacco is addicting, how medication can help and how it works
Help to choose a low stress quit date
Recommend elimination of cigarettes from home and remove potential triggers
Encourage other family members to quite (especially if present)
Medication
First line: Wellbutrin + Nicotine patch (dose tailored to daily cigarette use)
Start Wellbutrin/NRT 7 days prior quit day
Chantix if patient prefers or if contraindication to Wellbutrin.
No NRT while on Chantix, decrease cigarette consumption by half leading up to quit date
Discuss side effects (if not discussed, patient is likely to stop medication)
Provide written educational materials reinforcing discussion and medication regimen
Recommend patients consult the QUIT-NOW ( )
Document Smoking Cessation Intervention in EMR
Document in EMR

24. Length of Stay: Results to Date
P=0.056
P=0.089

25. Cost per case: Results to Date

26. Successes Summary
68 patients have undergone through the ERP LEB pathway in the 10 months post implementation
Improvement in observed to expected LOS: both total and post-operative
Reduction in 30-day all cause readmission
Reduction of surgical site infections
Decrease of average cost per case

27. Ongoing Challenges Poor compliance in certain metrics
PACT visit
Celebrex administration (Anesthesia)
Day of surgery mobility
Ordering of Pre-OP PowerPlan
Proper documentation of metrics (mobility)
Long term maintenance of reached goals
Patient participation (crucial to success)

28. Thank You